27 October 2012

It may be that you have never heard of John Dalli. I hadn't. He was, until recently, a European Commissioner. Now you know why you've never heard of him. Despite the importance of these people who make the laws that affect the lives of half a billion people we tend not to hear much about them. Nor do we plebs have any influence over who they are or what they do. I don't mean to imply that what they do is necessarily bad. In the case of John Dalli I suspect that quite the opposite is the case. Because John Dalli was European Commissioner for Health and Consumer Policy and was about to launch legislation related to tobacco control. Nothing too remarkable about that.

I used to go to school by bus. One day the bus conductor shouted, "Two more for the cancer ward." It was 1962 and the Royal College of Physicians had just published its report highlighting the link between smoking and lung cancer. The bus conductor had clearly got the message and had cheerily adopted a topical way of pointing out that there were still two seats on top where, for those readers too young to remember, the smokers were confined. I well remember having to take a seat next to the smokers upstairs. Even as a child I noticed that in the winter months the passengers on the top deck were constantly coughing and the windows were stained brown from smoke deposits. Friends at school who smoked used to do a party trick. After a deep draw on a cigarette they would inhaled deeply and then breathe out through a clean white handkerchief leaving an unsightly dark brown stain. It was no surprise to me that smoking might not be good for you.

What might have surprised me was how long it took for smoking to be controlled. Reasonable measures to protect people from the consequences of smoking have been opposed at every step by those making money from tobacco who have used every trick in the book. Now I'm older and know more and more about how the world works I'm not, of course, surprised.

Fast forward to 2012 and these battles are still going on. There's been progress but it has been slow. Children are still dying from the consequences of secondhand cigarette smoke and lung cancer, COPD and circulatory diseases continue to take their toll of adults.

Given this background, when I heard that John Dalli had resigned suddenly following an allegation from a tobacco manufacturer I couldn't help but smell a rat. So I did a bit of delving.

What are the facts? As is so often the case the facts are hard to come by. While it is said that John Dalli resigned suddenly it would seem that Dalli himself takes the view that he was ousted. Certainly he has lost his job. A second fact is that he was about to launch tough new tobacco legislation.

At this point I need to introduce you to snus. Snus is a form of tobacco which is placed between the gum and the lip. It comes in a variety of flavours: coffee, aniseed, elderflower, cranberry and mint. Nice to know if you fancy some but the important thing about snus is that it is banned in all European countries except Sweden. Which means, of course, that there is a company out there who is concerned about the future of snus and that company is Swedish Match.

It turns out that Swedish Match complained that a Maltese entrepreneur had asked for money in return for using his contacts with John Dalli - presumably with a view to ending the ban on snus sales in countries other than Sweden. Enter now Olaf. Olaf might sound like a Norseman but is actually the name of the European Commissions anti-fraud office. Olaf investigated and following the investigation John Dalli resigned or was made to resign with the consequence that progress of the long-awaited tobacco directive was frozen.

This did not escape the notice of my friend Sir Richard Thompson and my virtual friend Dr Clare Gerada who, along with Professor Lindsey Davies, wrote to the Guardian pointing out that delaying the directive would be a victory for the tobacco industry. Which does rather make me wonder if perhaps that was the point of the original complaint to the commission.

And then, to make matters even more mysterious and sinister, we learn that not two full days after the resignation of John Dalli the premises of three anti-smoking groups were burgled: the European Respiratory Society, the European Public Health Alliance and the Smoke Free Partnership.

It's a good story isn't it? Some would say it has all the makings of a Hollywood film. Why has it has so little publicity? Could it be that the lobbyists are now busy putting journalists off the scent? Or is that too fanciful? Who do you think produced this blog post cataloguing past allegations relating to John Dalli within hours of his resignation?

Are those of us who see conspiracies in these things bonkers? Draw your own conclusions.

14 October 2012

Was it here or on Twitter that I referred to Britain as the world's oldest democracy? I can't now remember and it doesn't matter. I can't even remember whether the ticking off I received was because we aren't the oldest or because we aren't a democracy. But it did set me thinking. I don't like to be wrong but I do like to be put right. That is the great strength of the wonderous new media of blogging and twitter. You can say something and be put right. There have been some interesting antics on twitter recently when people with entrenched views block those whose views differ. These people do not want to hear arguments; they just want to express their views. Banter with people like this becomes as sterile as an argument on the existence of God between Richard Dawkins and the pope. There really is no point.

One, but only one, of the reasons I had a blogging break was that I was a bit irritated by a very small number of these individuals with one-way minds making comments. They are not the sort of people who engage with arguments. They just want to sound off. And, since their arguments tend not to stack up, they bolster their ill-considered views with invective to try and give them some strength. I know that the louder they shout the more wrong they are likely to be but it does tend to render the debate somewhat sterile.

I have never really thought that I live in a true democracy. The world's oldest democracy is just a stock phrase I trotted out. It probably stems from the ruling classes intent on giving us plebs the illusion that we have some control over our lives. We don't. Not much anyway.

This point was brought home to me the other day. A group of local GPs came round to talk to the consultant body. It's an indictment that, although I knew all their names, I had scarcely ever met one of them before. Worse, for the first time, I met consultant colleagues I regularly correspond with. That's the modern hospital for you. The days of meeting people in the consultants' dining room are long gone. It been replaced with a snatched sandwich - and that's if you're lucky. It was clear that the GPs have a similar problem. Not only do they not know the consultants, they rarely meet their GP colleagues either.

The really surprising thing was the illusion these GPs had about the power of the consultants in the hospital. I have picked up this misunderstanding before from online comments from GPs. They really don't understand. GPs, you see, have very great influence over their own surgery. As many politicians like to point out, they are independent contractors.

If you are a senior GP you remember hospitals as they used to be. There was an illusion then that the consultants were in charge and ran the hospital. Perhaps there was a time when they did or, at the very least, they were listened to. But that was way back in history. They don't now. Not at all. They are scarcely listened to.

So why this extraordinary meeting with some local GPs when we all met for the first time? Well you've guessed it. It has to have been some sort of crisis. And you don't have to be very bright to guess that the Grumble hospital might be under threat of closure.

This then was what the local GPs came to discuss. They assumed that the consultants of Grumble hospital would have had in-depth discussions with the management about the hospital's future. They assumed there would have been lots of agonised discussions and hand wringing about the future of the hospital and what the consequences might be for our patients and for local GPs. It was an eyeopener for them to discover otherwise. One of Grumble's colleagues pointed out that our Chief Executive, when announcing some plan nobody much liked, announced that the hospital was not a democracy. It's not. It never has been and it never will.

Like most meetings nothing much came out of it though the GPs certainly learnt just how impotent today's consultants are. The interesting point for the consultants, though it may not have been a surprise, was that the local GPs had also not been consulted by their masters on the hospital closure. They had taken part in a formal public consultation process but, as was pointed out to them, formal consultation processes are more about telling the populace what is going to happen than listening to their concerns.

Does any of this matter? My own feeling is that we could do with a few benevolent dictators. But the hospital closures are not being driven by a need to improve healthcare by having fewer larger hospitals. The driver, though it is never admitted upfront, is a desperate need to save money.

Towards the end of the meeting the GPs launched their bombshell. If the planned loss of 1000 hospital beds goes ahead, there is no evidence that care in the community can take up the slack. This concept is just a management consultants' pipedream with absolutely no data to support it.

13 October 2012

Here is a recent editorial by Jacky Davis for the NHS Consultants' Association newsletter:

We really ought to have a black border around
the latest edition of the Newsletter, to mark the
death of the UK National Health Service. After a
2 year fight, the infamous Health and Social Care
Bill finally became law earlier this year. The
legislation was bulldozed through parliament
with the assistance of the Liberal Democrats, a
scandalous betrayal which will not be forgotten
or forgiven. In its final stages it was encumbered
with over a thousand amendments and is now
even more Byzantine and dangerous than when
it first saw the light of day. It was opposed by
every major organization representing health
care workers and degenerated from a bill sold
as empowering doctors and patients to one
battling the vested interests of the professionals.
Its passage was a low point for democracy in this
country. It became a matter of political pride and
personal prestige, an arm wrestling match in
which the coalition leadership had invested too
much to back down. It’s worth recalling why it matters so much.
This legislation is a bottle of snake oil, it
doesn’t do anything it promises on the label.
Cuts costs? No, costs will rise, with the ever
increasing financial burden of marketised
care not to mention £3 billion+ for the
‘reforms’ themselves. Cuts bureaucracy?
No, it replaces 3 layers with 7 and the CEO of
the NHS Confederation has recently warned
of a ‘tsunami of bureaucracy’. Gives power to
patients? No, patients will have less choice than
ever thanks to management referral centres,
reduced treatments, and the limited choice
already present in some parts of the country
where the private sector has taken over. It certainly doesn’t give power to doctors and
front line staff. GPs will be answering to CSUs run
by private companies and in London GPs have already been forced to pay for commissioning
‘support’ from the private sector. Management
consultants like McKinsey have made millions
so far and are anticipating many more millions
to come. At the same time GPs are taking the
blame for massive cuts in budget and we are
already seeing headlines blaming doctors for
service cuts and for denying care to patients.

Finally it cannot fail to adversely affect teaching
and training, core functions of the NHS. No
wonder the government defied the law and
refused to release the risk register.

So the H&SC Act represents a massive
redisorganisation of the service, so huge that
according to the Big Beast himself, Sir David
Nicholson (CEO of the NHS) it could be seen
from outer space. How was it possible that
such unwanted, undemocratic and destructive
legislation could get through against the
opposition of the profession? Part of the answer
must be that there was a dreadful failure of
medical leadership and much of the blame lies
at the door of our representative bodies. Many GPs were unfortunately but
understandably attracted by the idea of
commissioning while failing to notice that it came
accompanied by less attractive elements including
the drive to outsource any and all NHS services
to the private sector. The BMA, with GPs in the
driving seat, pronounce the bill to be a ‘curate’s
egg’, good in parts and announced that they
would have the tasty bits and manage the rest, thus
fatally missing the point of the tale of the curate’s
egg. Once part of the egg is rotten the whole thing
is inedible and this is as true for the HSCB. It is
woven of whole cloth, without the possibility of
taking up the attractive parts (if indeed there ever
were any) while rejecting the rest.

The BMA failed to consult its members over
the HSCB, relied too heavily on political
lobbying for ‘significant amendments’ which
never materialised and resisted coming out in
opposition to the bill until forced to by repeated
emergency motions at Council. By then it was
too late, and on the day the bill became law
Andrew Lansley was still claiming that he had
the support of the profession. The Royal Colleges, with a couple of honourable
exceptions, were the dog that didn’t bark in
the night. Not a sound was heard from most of
them on a matter which would massively affect
their members. They kept their heads down,
discussing instead (in the case of my own college)
important matters such as the move to a new
building rather than legislation which would
affect every aspect of their remit i.e. teaching,
training and standards. Finally in desperation at their silence several
campaigners, led by David Wrigley, a GP from
Cumbria, set up a website to encourage college
members to formally request emergency
meetings of their college so that they could
call for opposition. The resistance of college
officials to this move was a sight to behold,
and many interesting conversations took place
with people to whom it had clearly never
occurred that the members might notice what
was going on (or not going on ) at college HQ,
and what’s more might have the temerity to
question it. I’ll forever treasure the memory of a
phone call to someone at the RCS to say that we
had enough members signed up to call for an
emergency meeting. ‘But I’ve never heard
of you’ was the bad tempered response. Well
you have now and what’s more we have
the requisite number of names to request
a meeting. The great and the good who
represent us did not appreciate being called
to account. Once called to account almost all the colleges
found themselves faced with overwhelming
demands for opposition to the bill from their
members. Even then there were delaying tactics
but the message had gone out to the media that
doctors were united in their opposition to the
legislation. Unfortunately by then it was too
late to stop the bill.

A shining exception to this behaviour was the
RCGP, which regularly consulted its members
and whose president, Clare Gerada spoke
repeatedly about her concerns. Given the supine
position of the rest this was a heroic thing to do,
and attracted a lot of press coverage. Many firmly
believe that if the whole medical establishment
had had the courage to work together and speak
out against the bill it could never have survived
the joint onslaught of the profession. As it was
the complicit enablers, through silence or, even
worse, co-operation, betrayed the NHS, the
profession and our patients. Shame on them,
history will not remember them kindly. So are the prophets of doom right, and is
the NHS in England facing extinction? Well,
the news coming in is not good and already
we are seeing the vultures circling the NHS.
Significant contracts have already gone to
transnational corporations like Virgin and Serco,
the biggest company you have never heard
of. Virgin picked up community services in
Surrey, where presumably patient choice now
consists of Virgin or Virgin, and also ‘integrated
children’s services’ in Devon. As far as I know
they have no experience of providing the latter
but that doesn’t seem to matter in the brave
new world of outsourcing public services. The
core business of these transnational companies
is in winning government contracts regardless
of what they are for. They have the experience,
the legal expertise, and the deep pockets to
allow loss leaders if necessary and it is simply
unrealistic to think that small charities and social
enterprises can take on these huge companies
and win. Once they have the contract they then put
together the package, and the word is out that
community paediatricians are being urgently
sought, presumably to fulfil Virgin’s new
contract in Devon. It has been said that G4S,
awarded the security contract for the Olympics,
expected to take on operatives and deploy
them 3 days later. This is no way to run any
public service let alone the NHS and the G4S
Olympic fiasco certainly seems to have alerted
at least some in government to the dangers of
outsourcing public services. Vital public
services like the NHS can’t just simply be
allowed to disappear, and if private providers fail or walk away when profits don’t materialise
then the government has to step in. The result is
that profits are privatised while risk is socialised,
a convenient scenario for the private sector but a
recipe for disaster for the tax payer, the NHS and
those who rely on it.

Elsewhere GPs are waking up to the real world
of loss of autonomy to the Commissioning Board
and to commissioning support services, which
are likely to end up in the hands of – you’ve
guessed – the private sector. At what stage will
GPs decide that they can no longer ride the tiger
of the HSC Act and that it would be better to show
their disapproval with events by walking away
from commissioning? There are still those who
argue that they must remain involved otherwise
‘others will do it’ but that is the primrose path
to hell. We underestimate our strength as a
profession, but strength requires acting in unison
which requires strong leadership. We are still
waiting for it. Meanwhile the ‘Nicholson challenge’ of ‘saving’
£20 billion makes a nonsense of promises that
there would be no cuts to NHS services, and
thousands of front line jobs have been lost already.
And as longer and longer lists of treatments are
excluded from the NHS menu as part of these
McKinsey-driven “efficiency savings” fewer
people will be offered an acceptable choice;
instead many will have to choose between pain
and discomfort or paying privately. Personal
health budgets (PHBs) are another ideological
move, designed to facilitate the path to top ups
and co-payments while allowing top slicing by
20% to cope with the financial constraints. Martin
McKee’s article in the BMJ described how the
Dutch are moving away from PHBs while we are
rushing to embrace them – yet another example
of policy based evidence making? There are too many other depressing stories
related to the cuts and the ‘reforms’ to describe
them all but you might like to consider that
criminals can now run the NHS that NHS
patients will be able to ‘self fund’, the role
of the media during the listening pause,
predictions about the privatisation of hospitals, how patients lost their sight at a private
centre, and the scandal of over treatment in
the USA to chose but a few. And if you want more where those came from please follow Clive
(@clivepeedell), myself (@DrJackyDavis) and
KONP (@keepnhspublic) on Twitter. People who
don’t tweet often think that it is just about what
Wayne Rooney did last night but if you ignore
the celebrity trivia it is a wonderful campaigning
tool. Depending on who you follow you can get
all the news, articles and low down on health
and medical politics and never need know what
Madonna had for breakfast. Try it, you’ll be
pleasantly surprised, but - health warning – it is
dangerously addictive.

On an up note the Olympics provided some great
bread and circuses entertainment and Danny
Boyle became an instant NHS hero when he
featured the NHS during the opening ceremony.
Needless to say Tory MPs immediately saw
a conspiracy, but most recognised a genuine
wish to celebrate one of this country’s greatest
institutions, even while we are in danger of
losing it. Talking about great institutions and sporting
achievements, the award of Hero of the Year
goes to my Co Chair Clive who distinguished
himself by running from Nye Bevan’s statue in
Cardiff to the DoH in London, an unbelievable
feat which required 6 marathons in 6 days. We
salute him and his running partner Dr David
Wilson both of whom spent a great deal of time
in ice baths, although with or without added
gin and tonic is not reported. They were helped
along the way by the indefatigable Chris Burns
Cox who provided transport, logistical support
(and possibly the gin). Read about it here. Hypocrite of the Year award was a difficult
decision as ever but probably goes to the
Coalition government for rubbishing the
NHS at home while selling its brand abroad.
But there were plenty of other contenders for
the title. The year has been a busy one for your officers,
with many public talks, articles, letters in the
paper and arm wrestling with more conservative
institutions. Thanks go as ever to our equally
indefatigable president Peter Fisher, without
whom the organisation would not survive let alone prosper, and to you, our members, whose
subs allow us to help our sister organisations
KONP and the NHS Support Federation in their
important campaigning work. More members
mean more money and perhaps if you do one
thing to help the NHSCA in the next year it
should be recruiting at least 2 new members.
And meanwhile be thankful you’re not running
6 marathons...

The fount of Grumble's knowledge is that eighth wonder of the world: Google. If you type "Dr Grumble" into Google you will probably find at least some reference to the pseudonymous Grumble. The likelihood is that you will be referred back to this blog. Type in "National Health Action Party" and you might expect to be referred to the National Health Action Party's gleaming new web site. But you don't. Not, anyway, when Grumble does it.

Dr Grumble doesn't pretend to understand the vagaries of the internet. He's too old. To this day he wonders who pays for the multitude of connections that enables instant communications around the globe. Nor does Grumble grasp how Google, the best of all search engines, takes him to the exact page he wants from all the trillion or so out there. But it doesn't yet do the trick for the National Health Action Party.

But Grumble does know what a Google bomb is. If you have ever entered into Google "Famous French victories" and got back "Did you mean famous French defeats" then you have been the victim of a Google bomb. It's done by getting a lot a people to make malicious links.